The task force created by the Joint Commission at the November 2007 meeting to address a number of aspects of the MS.1.20 Standard has a major challenge in addressing the issues presented to it. In many respects, it is being asked to review a costly remedy for nonexistent problems.
In June 2007, the Joint Commission board approved the current version of its controversial MS.1.20 Standard in an effort to conclude three years of discourse and dissent. This standard addresses issues of medical staff bylaws and governance as well as the relationship between the medical staff and a hospitals governing board. This latest draft did not resolve significant practical and philosophical differences of opinion between the Joint Commission and the hospital industry.
In June 2004, in a response to a few high-profile disputes between hospital medical staffs, management and governing boards, the Joint Commission sought to require by means of a mandatory standard that nearly all matters which related to physicians status and activities in a hospital be addressed and governed by provisions in the hospitals medical staff bylaws. This was an attempt to limit the medical staff executive committees from adopting governing policies and procedures in documents which were not voted upon by the entire medical staff. In recent years, many hospitals medical staffs have expanded the role of medical executive committees so as to provide for a more effective document approval process in lieu of attempting to have the full medical staff vote on all proposed policies and procedures.
The initial effort of the Joint Commission in 2004 generated major objections and concerns from hospitals and various healthcare professional organizations. The proposed standard was seen as confusing, complex and counter to the realities of the decreased number of physicians who are today actively involved in medical staff affairs. Concerns also addressed the time and expense surrounding such major revisions to the governing documents of all hospital medical staffs. The criticisms and objections led the Joint Commission to withdraw the proposed standard in 2005.
In August 2006, following extensive discussions within the Joint Commission and with outside groups and trade associations, the Joint Commission proposed a revised MS.1.20 Standard and circulated it for field review. The revised version was perceived to still be an unnecessary and intrusive requirement for all hospitals. However, the field review draft of 2006 contained improved clarity and provided some flexibility in deferring to the judgment of the medical staff and hospital in deciding which provisions to include in the bylaws, rules, regulations or policy.
The June 2007 version of MS.1.20 returns much of the same objectionable terminology and required bylaw inclusion standards of the initial 2004 draft. It additionally requires restructuring the roles and responsibilities of the organized medical staff and the leadership functions of executive committees of medical staffs.
Collectively the changes reflect an incorrect and unrealistic view of todays hospital medical staffs. The standard perceives that an organized medical staffan undefined termwould as it did many decades ago, be a policy review and approval body. Further, under certain circumstances it could act independently of and even pre-empt actions of the medical executive committee. This is totally contrary to the realities of the functions of most hospital medical staffs today. The changed nature of hospital inpatient/outpatient services results in fewer meetings of the organized medical staff. It is not uncommon in some hospitals that the voting, active staff meet only annually or not even meet at all as a group. Even achieving meeting quorum requirements currently existing in most bylaws is a significant challenge. Additionally, to suggest or require as MS.1.20 does, that the entire organized medical staff can approve, and/or remove authority or reverse actions of the medical staff executive committee, would all but guarantee that the current voluntary service on a medical staff executive committee would soon be only a historical memory.
The task force should recommend to the Joint Commission board that it should discontinue attempts to require a template format for all hospitals medical staffs. The MS.1.20 Standard does nothing to advance the Joint Commissions legitimate interests of improving healthcare services. In fact, doing so may achieve just the opposite. Contrary to the stated desire to provide for collegial discourse among medical staff members and their leadership, the Joint Commission standard has introduced the means to completely reorder existing governance relationships. In its commentary, the standard urges organized medical staffs to presume that disagreements will arise and thus figure out in advance how to bypass the medical executive committee, remove its members and to reduce its authority.
Finally, the task force needs to be aware that a major objectionable concern regarding the initial version of MS.1.20 continues to exist with the 2007 version. That is, the significant costs that every hospital would incur in having to review, revise and amend medical staff bylaws to comply with the Joint Commissions perspective of what a medical staff should look like and resolve any resulting differences which could be generated in that process. Expenses in this respect includes the actual financial outlay that relates to any bylaw revision of significance. Such is far more than the costs of reprinting personal copies and drafts of a new set of multipage bylaws for every member of the organized medical staff. Rather, the heaviest expenses will be the immense amount of time which many personsphysicians, support staff, executive staff, legal or other paid consulting agents, etc.will incur in the process. In addition to the front-end expense, nearly every future element affecting physicians in the hospital will require complex and unnecessary bylaw amending procedures.
The task force should seriously consider recommending to the Joint Commission board that this four-year saga come to an end and the standard be withdrawn. The Joint Commission should define with some specificity what is expected of an accredited hospital and its medical staff and thereafter empower each hospital and its medical staff with what is determined to be the most effective format for meeting such expectations.
Dennis PurtellWhyte Hirschboeck Dudek S.C.Milwaukee
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